The Case for Prioritizing Diversity in the Transplantation Workforce to Advance Kidney Health Equity
Authors: Thomas Butler, Lee S. Cummings, Tanjala S. Purnell
Journal: Journal of the American Society of Nephrology (2022)

Disparities in access to transplantation experienced by socially disadvantaged populations remain a significant challenge to advancing kidney health equity in the United States.1,2 There remains a need for vital efforts focused on addressing factors driving disparities in kidney transplantation. Health disparity populations include racial and ethnic minority groups, and socioeconomically disadvantaged populations, population groups residing in medically underserved geographic areas, and sex minorities.12–3 In addition, 2020 brought about a national awakening catalyzed by the 8 minute and 46 second murder of George Floyd and other high-profile instances of racism. Now is the time to use this catalyst promoting the need for diversity in the transplant workforce. We propose a more diverse workforce as an answer to the problem of kidney transplant inequity. Systemic racism, which affects all facets of life, contributes to persistent disparities in health care.4 Notably, Black patients are disproportionately affected by kidney failure, and systemic racism, including structural barriers to kidney transplantation.4 Within the context of transplantation and kidney care, a classic example is Black patients being disproportionately harmed by delayed referrals to kidney care and transplant evaluation.4 These delays may be due, in part, to clinicians' implicit or explicit biases, including physician misperceptions about the benefits of transplantation for Black individuals. Black patients are also more likely to experience longer waiting times from starting dialysis to placement on the kidney waitlist, more likely to be cited as psychologically unfit for transplantation, and less likely to be waitlisted than White patients, even after adjusting for medical factors and social determinants of health.1,5,6,7 More recently, it was determined that inclusion of the race coefficient in eGFR was associated with delayed achievement of a clinical threshold for kidney transplant referral and eligibility, thus worsening kidney transplant disparities by delaying referral for Black patients.8 Strategies to tackle racism are critical if disparities in kidney care and transplantation are to be reduced. "It is not our differences that divide us. It is our inability to recognize, accept, and celebrate those differences." Audre Lorde Disparities in kidney transplantation may be partly attributed to the lack of diversity in the fields of transplant surgery and nephrology. The National Institutes of Health has acknowledged that increasing diversity of the biomedical sciences workforce would improve health equity by increasing the capacity to identify, address, and eliminate health disparities. Diversity helps to mitigate the harm of implicit biases that are inherent in us all; race concordance among providers has also been associated with better health outcomes and process measures for Black patients.9,10 Increasing diversity among providers may also alleviate reported distrust and fears about organ donation and transplantation in socially disadvantaged communities. Unfortunately, diversity among transplant surgeons has been historically low, with only 5.5% self-identifying as Black, which mirrors the general surgery Black representation at 5%, whereas the White to non-White transplant workforce ratio has increased by 35% from 2000 to 2013.10 This trend is worse in nephrology where only 3.3% of transplant nephrologists identify as Black and 7.9% identify as Hispanic.10 In 1978, Black men accounted for 3.1% of the medical student body in the United States. Then, 40 years later, that percentage has fallen, according to the Association of American Medical Colleges. The Role of Professional Societies in Promoting Diversity in Transplantation National recognition of worsening health care disparities in several key areas, and protests to systemic racism, inspired support for ongoing and new efforts within the transplant and nephrology professional communities in the United States. For instance, the American Society for Transplant Surgeons (ASTS) Diversity, Equity and Inclusion (DEI) Committee has spearheaded several initiatives aimed at eliminating disparities in transplantation, such as the creation of a new DEI/Anti-Racism online module on the Academic Universe designed to educate members and transplant fellows nationwide on issues of racism in transplantation; implementation of new cultural competency themed-sessions at annual ASTS meetings; and dedicated funds to provide stipends for under-represented minorities to attend the annual Winter Symposium. The ASTS also launched a national campaign, ASTS Boldly Against Racism, to directly address racism as a root cause of racial disparities in transplantation. These collective efforts resulted in the launch of the ASTS Boldly Against Racism Task Force and a new grant to promote diversity in transplantation and support research to address transplant disparities. Furthermore, the creation of a new ASTS DEI Officer role was voted into the ASTS bylaws in June 2021, and will result in ascension to the ASTS presidency at the term's end. Another example is the American Society of Transplantation, which has championed efforts to promote diversity in transplantation, including the formation of a new Inclusion, Diversity, Equity, and Access to Life Committee, and creation of a new Advancing Equity in Organ Transplantation Award. The Boldly Against Racism Inclusion, Diversity, Equity, and Access to Life committee has hosted webinars and extended its mission to work in support of the elimination of systemic racism in the field of transplantation. Among nephrology professional societies, the American Society of Nephrology (ASN) has worked to promote diversity, inclusiveness, and equity in the field through several longstanding initiatives led by the ASN Diversity, Equity, and Inclusion Committee. These initiatives include dedicated funding to promote diversity in nephrology (e.g., ASN-Harold Amos Medical Faculty Development Award); research grant funding to address disparities in kidney care; educational and networking sessions at ASN Kidney Week annual meetings; and DEI-themed online modules (e.g., gender-affirming kidney care and lesbian, gay, bisexual, and transgender equity). In 2020, the new ASN Health Care Justice Committee was formed to promote social justice in health care, research, and nephrology education. Other successful organizations include the National Kidney Foundation (NKF), which has established priorities in research that aim to expand diversity and inclusivity of clinical trials, develop and test interventions to reduce health disparities, and support implementation science. Notably in 2020, the NKF and ASN combined forces to form the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease, to reassess the inclusion of race in the estimation of GFR in the United States. Team diversity also helps dispel bias and builds trust in our transplant community. Recommendations and Challenges to Moving the Field Forward Moving forward, the pipeline of diverse transplant surgeons and nephrologists must be refreshed and multiplied. We can start this process early by promoting efforts to facilitate greater exposure of racial/ethnic minority grade and high school students to science, technology, engineering, and mathematics. At the undergraduate level, there are a multitude of National Institutes of Health–sponsored programs, which increase minority students' exposure to biomedical research, and foster the relationships needed for careers in transplant and nephrology. We should also adopt evidence-based practices that have been demonstrated to promote equity in transplantation, such as those used by the National Minority Organ Tissue Transplant Education Program. These include the use of community health workers, collaborating with communities, and training of staff for delivery of culturally appropriate services. We must include our transplant coordinators, nurses, pharmacist, social workers, nutritionist, and advocates to the equation of diversity. Our patients interact with the team, just as much, if not more on a daily basis. Team diversity also helps dispel bias and builds trust in our transplant community. Professional societies should play a lead role in addressing issues around disparities and diversity, specific to their specialties, and set metrics for progression and accountability. These goals should ideally be explicitly stated within society bylaws, and should encourage comradery between societies, with similar goals when appropriate. It is within the power of most professional societies to identify and prioritize initiatives to address issues around racism and lack of diversity, such as the formation of dedicated committees to address these problems, and dedicated funding and grant opportunities. We should also learn from societies, within and outside of the field, that have long prioritized workforce diversity and health equity, including the Society of Black Academic Surgeons, the National Minority Organ Tissue Transplant Education Program, and National Medical Association. In conclusion, both the transplant surgery, and the transplant nephrology professional communities, agree on wanting the best health outcomes for our patients. We have seen how systemic racism negatively affects our communities, and increasing diversity in the workforce is a direct counterpunch. In the meantime, awareness of unconscious bias, which affects us all, may be achieved using easily accessible tools, provided by organizations such as the National Institutes of Health. Together, as a diverse transplant workforce, we can better achieve the common goal of improved kidney health equity for all. Disclosures T. Butler and L.S. Cummings are members of the ASTS Diversity, Equity, and Inclusion Committee. T. Butler reports receiving research funding from Gift of Life. T.S. Purnell reports being Chair of the ASTS Diversity, Equity, and Inclusion Committee, a member of the ASTS Boldly Against Racism Task Force, Co-Lead of the Education Workgroup for the ASN Health Care Justice Committee, a member of the Governing Board of Directors for the National Minority Organ Tissue Transplant Education Program, and has an advisory or leadership role in The Living Legacy Foundation. Funding This work was supported by the Agency for Healthcare Research and Quality grant K01HS024600 (to T.S. Purnell).